Options are available to traditional trocar
While the debate over shielded vs. unshielded trocars goes on among surgeons and day surgery program managers, there are other options to the use of trocar entry to establish a primary insertion site for laparoscopic surgery. The four most common alternatives are:
Insufflation with a Veress needle. With this approach, a 16-gauge needle is inserted into the abdominal cavity. Next, gas is blown in to create a work cavity and lift the abdominal wall away from organs and other vessels.While this procedure is just as "blind" as a primary trocar insertion, the smaller needle requires less force for entry, says C. Randle Voyles, MD, a general surgeon at Mississippi Surgery Center in Jackson. Even if punctures or lacerations occur, they are generally smaller and less severe than trocar injuries, he adds. A disadvantage to this procedure is that the needle cannot accommodate an endoscope, so position cannot be verified before insufflation, says Voyles. This lack of verification can increase the risk of a gas embolism and death in the rare case of insertion into a blood vessel, he says.
Hasson Technique. Also called the cut-down technique, the Hasson Technique requires the surgeon to make a 2 to 3 cm cut to expose the fascia. Retractors and a blunt trocar are used to penetrate through to the abdominal cavity.This is not a blind procedure because surgeons are looking directly at the area through which the trocar is penetrating. The blunt trocar minimizes the risk to vessels and results in a lower incidence of punctures or lacerations, Voyles says. The disadvantage is a potentially longer healing period for patients. Surgeons also must be careful to suture the opening well to prevent gas from leaking out of the cavity around the cannula, he adds.
Radially expanding sleeve system. A braided polyurethane sleeve that is slightly larger than a Veress needle but can expand radially to accommodate large pieces of equipment makes up the system marketed by InnerDyne Medical of Sunnyvale, CA. The Food and Drug Administra-tion has allowed the company to bill this laparoscopic entry system as safe after the company presented data in January 1999 that demonstrate a dramatic reduction in trocar entry injuries.With this approach, the Veress needle or blunt trocar is placed within the sleeve and inserted into the abdomen. The needle or trocar is removed, and a cannula is placed into the sleeve. Advantages of the sleeve include the capability of inserting a laparoscope prior to insufflation and the radial expansion of muscle fibers that produce small tears rather than the larger punctures of traditional trocars.1
The optical trocar. Trocars that contain a window at the tip and are designed to handle a laparoscope to look through the window enable surgeons to view the tissue layers during penetration and to see the abdominal cavity after penetration. Ethicon Endo-Surgery of Cincinnati, United States Surgical of Norwalk, CT, and Karl Storz Endoscopy-America of Culver City, CA, are among the manufacturers that offer an optical trocar. (See source box, below, for information on these manufacturers.)Some of the optical trocars incorporate a cutting device that can be used on a previously distended cavity. An advantage of the optical trocar is the surgeon’s view of the actual penetration, says Vangie Paschall-Dennis, RN, CNOR, laser endoscopy coordinator for Promina Gwinnett Health System in Lawrenceville, GA.
Reference
1. Galen DI, Jacobson A, Weckstein, LN, et al. Reduction of cannula-related laparoscopic complications using a radially expanding access device. J Am Assoc Gynecol Laparosc 1999; 6:79-84.
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